Integrating social epidemiology into immigrant health research: A cross-national framework
Highlights
► Immigrant health research needs to address the social determinants of health cross-nationally and along the lifecourse. ► A cross-national framework integrates the sending and receiving context, the migration process, and transnational ties. ► Newer research on socioeconomic patterning of health contextualizes immigrant health in sending and receiving countries. ► Progress in immigrant health research is linked to an improved understanding of cross-national factors.
Introduction
Migration between countries is at higher levels than ever before. The movement of people across national boundaries influences economic development, labor, and population health (World Health Organization, 2010). In response to these trends, the number of policies with implications for immigrant health, and the number of studies on immigrant health have steadily increased over the last two decades.
The realities of immigration have resulted in cross-national policy responses (Zimmerman, Kiss, & Hossain, 2011). National economies, the development of sending communities, and individual families in sending societies partly depend on immigrant productivity in receiving countries and the monetary remittances of immigrants (Inter-American Development Bank, 2009). Recognizing the importance of remittances for sending societies, along with the often limited access to health and social services for immigrants in receiving societies, some sending countries have established cross-national services to assist their immigrant co-nationals. Thus, it is increasingly recognized that health and social policies within and between countries can have substantial influence on the health of immigrants, their families, and the population health patterns within sending and receiving countries (Zimmerman et al., 2011). This wider recognition of the importance of cross-national processes, however, is not yet consistently reflected in the scholarship on immigrant health.
In addition, research on immigrant health is often approached as a “specialty” topic involving a discrete de-contextualized population rather than a topic that is central for understanding patterns of population health within and between sending and receiving countries. Frequently, the health of immigrants in host societies is examined using theoretical frameworks (e.g., acculturation) that emphasize cultural explanations, while the social determinants of health framework, which emphasizes social and structural explanations, is less commonly utilized. When social determinants (e.g., SES, gender) are examined, they are infrequently placed in the context of the sending and/or receiving society, or within the context of migration and adaptation processes. Important empirical studies dating primarily since 2000 (e.g., Buttenheim, Goldman, Pebley, Wong, & Chung, 2010; Gong, Xu, Fujishiro, & Takeuchi, 2011; Kimbro, Bzostek, Goldman, & Rodriguez, 2008) have addressed some cross-national issues, such as the extent of health selection in migration processes. However, few studies integrate comprehensive theoretical frameworks of cross-national influences on immigrant health.
The need for a comprehensive cross-national framework is increasingly recognized, as highlighted in a recent series of papers that focused on policy responses to address the health of immigrants across national boundaries (Zimmerman et al., 2011). Our paper draws upon several theories of migration with the goal of integrating these diverse and independent research streams in order to provide a more cohesive conceptual basis for the study of immigrant health.
Our goal is to propose an integrative conceptual framework for understanding immigrant health from a cross-national perspective—that is, one that explicitly and systematically considers the possible influences of both the sending and receiving countries on immigrant health. To this end, we draw upon literature in the fields of economics, sociology of immigration, and social epidemiology. We begin by defining our use of the term “cross-national” and discussing the framework and its elements. We then elaborate on the theoretical foundations of this framework and the methodological challenges for undertaking research on immigration and health using this framework. We conclude with examples of emerging research in this area and directions for future research.
Section snippets
What is a cross national perspective?
We use the term “cross-national” to refer to influences on health outcomes that derive from immigrants' sending and receiving contexts and from the immigration process. While some of these influences are exchanges between places (e.g., economic remittances), others occur at different points in time and without agency on the part of immigrants (e.g., health-related exposures during childhood in the sending country). Thus, the proposed cross-national framework is different from the concept of
A cross-national framework for understanding immigrant health
The health of non-immigrants is primarily influenced by the societies they live in, while the health of immigrants (as well as their families and communities of origin) is embedded in both sending and receiving societies. As depicted in Fig. 1 and discussed further below, sending-country (i.e., country of origin) factors may influence immigrant health before and after immigration, along the lifecourse, alone or in combination with receiving-country (i.e., country of destination) factors. The
Theories to inform cross-national research
In the past, research on immigrant health had often favored conceptual frameworks and interpretations that focused primarily on cultural factors, e.g., acculturation. In the last decade, researchers have called for greater attention to the social determinants of immigrant health (Hunt, 1999; Hunt, Schneider, & Corner, 2004; Viruell-Fuentes, 2007), and empirical studies are increasingly using a social determinants framework. For example, several studies have examined socioeconomic gradients in
Research using a cross-national perspective
An integrated cross-national perspective has not been consistently applied in health research, though we have found four bodies of empirical work that explicitly acknowledge or imply a cross-national framework: immigrant health selection; socioeconomic patterning of health among immigrants; health effects of pre-immigration factors; and health effects of remittances. We briefly discuss these approaches and highlight how they can inform cross-national research.
Directions for future research
A cross-national framework suggests several substantive research areas for future work on immigrant health, including: (1) examining the population-level implications of immigration for health in both receiving and sending countries; (2) further investigating whether immigrants from and to different regions are health selected, and the health implications for immigrants following migration; (3) improving the conceptualization and measurement of migration histories and adaptation processes, and
Conclusion
Progress in immigrant health research is linked to an improved understanding of population health patterns in sending and receiving societies. Conceptually, methodologically, and analytically, immigrant health research needs to be better integrated into social epidemiological research. At the same time, immigrant health research offers conceptual and empirical insights and analytic opportunities to advance social epidemiological research. The integration of immigrant health research with social
Acknowledgments
The authors are founding members of Place, Migration and Health: A Cross-national Research Network (PMH). They gratefully acknowledge the support of other PMH members, especially Barbara Krimgold and Debra Perez, as well as grant support for PMH from the Center for Advancing Health, The Robert Wood Johnson Foundation, and the David Rockefeller Center for Latin American Studies at Harvard University.
The authors also acknowledge support from the W.K. Kellogg Foundation to Dr. Acevedo-Garcia; from
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